tag:theconversation.com,2011:/us/topics/mental-health-care-15150/articlesmental health care – The Conversation2018-07-27T13:35:00Ztag:theconversation.com,2011:article/1001432018-07-27T13:35:00Z2018-07-27T13:35:00ZWhy CBT should stop being offered to people with schizophrenia<figure><img src="https://images.theconversation.com/files/229317/original/file-20180725-194124-xrkocz.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p><a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">Cognitive behavioural therapy</a>, or CBT, has in the past decade become a standard tool for helping people with schizophrenia deal with their symptoms. Recent developments, however, raise serious questions about how effective this talking therapy really is for this illness.</p>
<p>Despite strongly advocating that all people with schizophrenia should be offered CBT, the National Institute for Health and Care Excellence (NICE) – the organisation that evaluates treatments for the NHS – has inexplicably neglected to update its evidence base <a href="https://www.nice.org.uk/Guidance/CG178">since 2008</a>. In the intervening years the number of randomised controlled trials – the gold standard for clinical research – assessing symptom reduction through CBT has doubled, and many of them cast doubt on the institute’s recommendations.</p>
<p>Very few trials had reported on the impact of CBT on social and professional functionality, or quality of life, so with this in mind we recently published the first <a href="https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0243-2">meta-analysis</a> assessing the impact of CBT on these aspects. </p>
<p>The results were not positive. While we found that CBT initially improved the ability of patients to function, the benefit was shortlived. CBT failed to alleviate the distress associated with the symptoms of psychosis. CBT also failed to improve quality of life, as measured in a patient’s sense of self, hope, well-being, relationships and so on. Indeed, not one CBT trial has ever reported a rise in quality of life for people diagnosed with schizophrenia.</p>
<h2>A growing weight of evidence</h2>
<p>This was just the latest study to raise question marks, and a 2014 <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/cognitivebehavioural-therapy-for-the-symptoms-of-schizophrenia-systematic-review-and-metaanalysis-with-examination-of-potential-bias/10B5A4BB22C8A82FE55E578A15975753">meta-analysis</a> by our research group had already concluded that claims that CBT alleviates classic symptoms such as delusions are “no longer tenable”.</p>
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<span class="caption">CBT helps with a great many things. But perhaps not schizophrenia.</span>
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<p>A 2014 <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/adapted-cognitivebehavioural-therapy-required-for-targeting-negative-symptoms-in-schizophrenia-metaanalysis-and-metaregression/5CAF1F3E1ACE4BB541DF768A0B40BCF0">meta-analysis</a> from the Netherlands found that almost none of the latest studies reported reductions in schizophrenia symptoms, such as social withdrawal, apathy, or “emotional blunting” (having no positive or negative emotions). The authors concluded: “CBT studies focused on psychotic symptoms might not work as well in reducing negative symptoms as previously thought.” </p>
<p>Furthermore, a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163968/">Cochrane review</a>, an authoritative voice on evidence-based healthcare, concluded that CBT showed “no clear and convincing advantage” over other, sometimes much less sophisticated, therapies, or even simple, non-technical approaches such as befriending. This involves talking with the patient about neutral topics of interest, such as music, sport, books, pets and so on.</p>
<p>A smaller amount and lower quality of evidence was required to establish CBT as an intervention, than now exists for it to be rejected. Earlier trials of CBT for schizophrenia – such as those reported by NICE – were much less rigorous than their modern counterparts. For example, many early researchers did not use blind outcome assessment – that is to say, they knew which of their subjects had received CBT and which had not, potentially leading to <a href="https://theconversation.com/confirmation-bias-a-psychological-phenomenon-that-helps-explain-why-pundits-got-it-wrong-68781">confirmation bias</a>. These earlier trials spuriously inflated the apparent benefits of CBT <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/cognitivebehavioural-therapy-for-the-symptoms-of-schizophrenia-systematic-review-and-metaanalysis-with-examination-of-potential-bias/10B5A4BB22C8A82FE55E578A15975753">five or six times over</a>. </p>
<h2>Risk and reward</h2>
<p>One of the main factors that can lead to the withdrawal of an intervention is if harm is seen to outweigh benefit. Psychological interventions such as CBT are often assumed to cause no harm, but <a href="https://www.sciencedirect.com/science/article/pii/S0920996418301907">a recent study</a> urged caution. It warned: “The measurement and reporting of adverse effects in trials of psychological interventions for psychosis (and other conditions), is extremely poor.”</p>
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<span class="caption">There is a question mark over whether patients actually want CBT in the first place.</span>
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<p>The fact that harm is not routinely assessed, or is poorly assessed in psychotherapy trials should raise a red flag over recent calls for CBT to be an <a href="https://www.sciencedirect.com/science/article/pii/S0920996418301622">alternative to antipsychotic medication</a>. The single recent, relevant <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30096-8/abstract">study comparing the two treatments</a> showed that adding CBT to antipsychotic medication gave no significant additional benefit, while adding antipsychotic medication to CBT produced significant improvement in symptoms. </p>
<p>But even setting aside efficacy and potential harm, do the patients themselves actually want CBT? Evidence suggests not – according to the <a href="https://www.rcpsych.ac.uk/pdf/FINAL%20report%20for%20the%20second%20round%20of%20the%20National%20Audit%20of%20Schizophrenia%20-%208.10.14v2.pdf">2014 National Audit of Schizophrenia</a> published by the Royal College of Psychiatrists, more than half of those offered CBT decline it.</p>
<p>The evidence used by NICE is low quality and outdated, and their endorsement of CBT is in dire need of reconsideration. There are serious doubts as to whether CBT actually reduces schizophrenia symptoms, and now also whether it improves key outcomes such as functionality, quality of life and symptom-related distress. If we want psychological interventions to evolve, then new research to be directed at developing and assessing alternative treatments. </p>
<p>And if we want an accessible, cost-effective and equally potent alternative in the meantime, why not listen to the Cochrane group. We might do just as well with befriending.</p><img src="https://counter.theconversation.com/content/100143/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Laws does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Cognitive behavioural therapy has become a go to for clinicians treating symptoms of schizophrenia. Recent studies suggest that this is a mistake.Keith Laws, Professor of Cognitive Neuropsychology, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/839532017-09-17T10:44:59Z2017-09-17T10:44:59ZWhy people who attempt suicide need more than meds<figure><img src="https://images.theconversation.com/files/186050/original/file-20170914-8984-ygym4b.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Meet Jane. She’s 22 years-old. She has a quirky smile and an unconventional sense of humour. She’s finished high school and has a young baby. She has been unemployed for a long time.</p>
<p>When her mother died, she was devastated. Her only support structure was gone. And the responsibilities of being an unemployed single mother became too much. She felt alone and unsupported. She felt that she would never escape the unemployment trap. She saw no alternatives.</p>
<p>So she tried to take her own life. She ended up in an intensive care unit and needed to be in hospital for more than a month, having multiple surgeries and medical interventions for her self-inflicted injuries. </p>
<p>Jane is not alone. In South Africa it’s estimated that about one completed suicide takes place every hour. This is on a par with developed countries like the <a href="http://econtent.hogrefe.com/doi/abs/10.1027/0227-5910/a000293?journalCode=cri">US and UK</a>. The <a href="http://www.sciencedirect.com/science/article/pii/S0140673615002342">statistics</a> also show that people who attempt suicide are at high risk of repeating the action. They are also 20 to 30 times more likely than the general population to die by suicide. </p>
<p>If Jane had better access in her community to integrated psychological, social and psychiatric interventions she would possibly not have endangered her life and landed in hospital. A <a href="http://www.bmj.com/content/317/7156/441?linkType=FULL&amp;resid=317/7156/441&amp;journalCode=bmj">growing body of research</a> shows that integrating these three services are best practice for reducing suicide risk.</p>
<p>But this isn’t the case in South Africa. People are able to access medical care at their clinics – which is the first point of care for most – but psychologists, psychiatrists and social workers are not always part of the primary health care setting. </p>
<p>In addition to the integrated services, mental health care providers also need to understand what people who attempt suicide need to prevent future episodes. Globally this has <a href="https://link.springer.com/chapter/10.1007/978-1-4939-2920-7_20">hardly been done</a>. </p>
<p>Our <a href="http://journals.sagepub.com/doi/abs/10.1177/2055102917726202">study</a> set out to get an insider perspective from people who had made medically serious suicide attempts. Our aim was to identify ways in which future suicide risk could be reduced by learning from the patients.</p>
<p>Our findings confirm that a integrated approach to suicide prevention is needed in South Africa. But it also highlights the need for person-centred, psycho-social support and psychiatric services at clinics in communities. </p>
<p>And in addition to building patient’s resilience, the solutions need to address social and economic issues, such as poverty, inequality, and interpersonal violence. </p>
<h2>Consulting the real experts</h2>
<p>As part of our study we interviewed patients admitted to an urban hospital after a medically serious suicide attempt. The patients we saw ranged from 18 to 67 years old.</p>
<p>In the stories they told we recognised many well known risk factors for suicide: lack of relationships, social isolation, loneliness, interpersonal conflict, substance use, severe depression, poor problem-solving skills, feelings of hopelessness and being trapped, as well as disempowered. </p>
<p>Patients from low-resource communities also had additional problems. Firstly they could not access psycho-social services at a primary health care level or get on-going psychiatric help.</p>
<p>Many described how they struggled to access mental health care at a community level. They often had to wait for a long time before they could see a mental health professional. And when they finally got a turn, they felt rushed by the psychiatric service providers. Their community clinics and day-hospitals often did not have counselling services – there were only nursing sisters they could see once a month, if they were lucky. </p>
<p>Some patients also struggled to get the medication they needed. Reasons included having to taked time off work every month to go to the clinic and often having to wait in long queues. As a result, they would often go home empty handed. </p>
<p>In addition to these challenges, they live in communities with oppressive social and economic conditions. Endemic violence, structural poverty, enduring inequality and continuous trauma all contributed to making life unbearable. </p>
<p>Our findings draw attention to the health care context in which suicide attempts happen in South Africa. There are a number of problems with the structure and delivery of health care that impede mental health promotion at a comunity-based primary health care level. </p>
<p>The significant mental health treatment gap is one problem. There is a shortage of public mental health resources, and a lack of access to effective and affordable mental health care. </p>
<p>The other challenge is the fact that primary health care in the country is still predominantly biomedically orientated, in other words there’s still a focus on dispensing medicine rather than providing more counsellors and integrating social services into clinics.</p>
<h2>A new approach</h2>
<p>It’s difficult to prevent suicides, partly because so many different factors contribute to the problem. But the situation is not hopeless. There are effective interventions for suicide prevention and help is available.</p>
<p>Our study provides important insights into the type of support patients say they need. These requests are not unreasonable or unimaginable: appropriate, affordable, accessible, ongoing psych-social and psychiatric care.</p>
<p>These are recommended in international suicide prevention guidelines and best practice standards for delivering mental health care.</p>
<p>South Africa has the policies and legislation in place to support such an approach. For example, plans have been made to create posts for registered counsellors in the health care system and counsellors have been trained to fill these posts. </p>
<p>But there have been delays in implementing these policies into all primary health care settings. Resources are scarce but there are also issues around allocating and managing resources.</p>
<p>It’s equally important to recognise the socio-economic and contextual problems people face in low and middle income countries. These need to be addressed at a political and economic level to reduce suicidal behaviour. This requires different government departments and community organisations to work together to address problems such as violence, substance use, poverty and inequality.</p><img src="https://counter.theconversation.com/content/83953/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Bantjes receives funding from the South African Medical Research Council.</span></em></p>People who attempt suicide can access medical care at their clinics but psychologists, psychiatrists and social workers are not part of the primary health care setting.Jason Bantjes, Senior Lecturer in the Psychology Department, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/825552017-09-05T14:49:19Z2017-09-05T14:49:19ZIntegrated care can help prevent suicide among substance users<figure><img src="https://images.theconversation.com/files/184702/original/file-20170905-13766-bz5qkw.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There is strong evidence that people with substance use problems often also have other psychiatric disorders such as depression and psychosis, that in turn is linked to suicidal behaviour. Those who do not receive help are at a higher risk of committing suicide than the general population. </p>
<p><a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742009000500022&amp;script=sci_arttext&amp;tlng=pt">More than 1 in 10 South Africans</a> have a lifetime diagnosis of a substance use disorder – higher than European countries. <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-926">South Africa’s youth</a> are particularly at high risk of alcohol, marijuana, and tobacco use. In the country about <a href="http://journals.sagepub.com/doi/abs/10.1177/0081246313482627">40% of the people</a> who commit suicide are under the influence of alcohol at the time of their death. And studies from other low and middle-income countries show that substance use is a clear risk factor for suicidal behaviour.</p>
<p>People with substance use problems therefore need effective and accessible mental health care. In developed countries, like the <a href="https://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html">United States</a>, the <a href="http://webarchive.nationalarchives.gov.uk/20130104225636/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019548.pdf">United Kingdom</a>, and <a href="https://www.lifeinmindaustralia.com.au/docs/LIFE-framework-web.pdf">Australia</a>, governments have created national suicide prevention strategies. </p>
<p>They use multilevel interventions like improving access to mental health services for high risk groups, creating public education campaigns, and improving the capacity of health care workers to recognise and respond to suicide warning signs.</p>
<p>But in low resource settings – like South Africa – this is not the case. There is no national suicide prevention strategy in South Africa. There are also many factors that impede suicide prevention in the country. This includes a lack of intersectoral collaboration and the lack of person centred psycho-social care at a community level. Effective suicide prevention for people with substance use problems requires integrating psychiatric care along with psychological and social services. </p>
<p>As part of <a href="http://rdcu.be/uWT4">our research</a>, we asked mental health care providers working with suicidal people with substance use disorders in Cape Town about their perception of barriers to suicide prevention. </p>
<p>Our findings suggest that one of the biggest barriers to suicide prevention is the fact that psychiatric services and substance use services are often not integrated. As a result, people who have substance use disorders do not receive the psychiatric, psychological, and social care that they need to prevent them from engaging in suicidal behaviour.</p>
<p>These structural challenges with the provision of services, along with situation and contextual factors such as poverty, inequality, and interpersonal conflict, create a fertile ground for putting people with substance use problems at high risk of suicide. </p>
<p>Without integrated care and intersectoral collaboration, it will continue to be difficult to prevent suicide in people with substance use disorders. </p>
<h2>Limitations</h2>
<p>In South Africa and globally, suicide prevention strategies have largely been framed within a biomedical paradigm. This assumes that suicidal people are mentally ill and simply require psychiatric treatment.</p>
<p>This approach focuses on individual risk factors, and improving access to psychiatric care. Although strategies like this are important they do not always serve the needs of people with substance use problems who are suicidal. </p>
<p>Part of the problem with strictly biomedical approaches to suicide prevention is that they do not recognise that people with substance use problems often face a range of serious social, economic, contextual, and interpersonal challenges. </p>
<p>People who have substance use problems can seek help at treatment facilities. But there are many challenges that make accessing these facilities difficult. </p>
<p>Firstly, there is a shortage of services that provide effective care. In South Africa, for example, there are only <a href="http://www.mrc.ac.za/adarg/sacendu/SACENDUupdatejUNE2017.pdf">75</a> treatment facilities registered with the Department of Social Development. These facilities served only 8787 treatment seekers in the second half of 2016.</p>
<p>Secondly, substance use treatment services are often woefully under resourced. </p>
<p>Thirdly, people have trouble accessing treatment because of financial and geographical barriers. For example, in the Western Cape province, only <a href="http://www.mrc.ac.za/adarg/sacendu/SACENDUBriefDec2016.pdf">about 50%</a> of people receiving treatment for substance use, access care at state sponsored facilities. </p>
<p>The resource constraints mean that most treatment facilities have to limit the amount of care they can provide each person. Many facilities are also forced to provide brief interventions that only focus on substance use, without addressing any of the other social and economic problems that might be linked to substance use. </p>
<h2>Integrated care is key</h2>
<p>Our study highlights the range of factors that prevent health care workers in South Africa from providing effective care and preventing suicide among people with substance use disorders. </p>
<p>Poverty and inequality prevent many patients from accessing facilities. Furthermore, breakdown of families, unemployment, social isolation, exposure to trauma, homelessness, and stigma all contribute to high rates of suicide among people with substance use problems. These are important factors that need to be addressed as part of any national suicide prevention strategy. </p>
<p>Health care providers said that they felt powerless to address these problems which fall outside the realm of the health system. Yet, these factors have a significant impact on people’s mental health. </p>
<p>Our study showed that health care providers working with people with substance use disorders need to be supported to do their difficult work. Health care providers described their work as emotionally provocative and said they felt overwhelmed and distressed providing care to suicidal patients. Sometimes they felt powerless to prevent suicides. Those who were supported by colleagues said this helped them to do their work without becoming overwhelmed, despite its challenges.</p>
<h2>Multilevel strategies are needed</h2>
<p>The <a href="http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&amp;ua=1">World Health Organisation</a> has recommended that suicide prevention interventions should target high risk groups. This is important given that substance use is a major public health problem in South Africa. </p>
<p>The responsibility for preventing suicide in people with substance use disorders may need to extend beyond the health care system and treatment facilities. Better intersectoral collaboration, more integrated health services, and addressing contextual factors are required to effectively prevent suicide in people with substance use disorders.</p>
<p>Clearly there is a need to provide more care for the carers, so that the professionals who do the difficult work of providing mental health care services are adequately supported.</p>
<p>Our research also draws attention to the need for mental health care providers to be well trained in providing evidence based interventions for suicide prevention and problems associated with substance use.</p><img src="https://counter.theconversation.com/content/82555/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Goldstone receives funding from the National Research Foundation. </span></em></p><p class="fine-print"><em><span>Jason Bantjes and Lisa Dannatt do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In South Africa one of the biggest barriers to suicide prevention is that psychiatric and substance use services are often not integrated.Jason Bantjes, Senior Lecturer in the Psychology Department, Stellenbosch UniversityDaniel Goldstone, Researcher in Psychology, Stellenbosch UniversityLisa Dannatt, Consultant Psychiatrist Department of Psychiatry and Mental Health, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/819902017-08-13T21:11:14Z2017-08-13T21:11:14ZThe bad buildings scream – lessons from Don Dale and other failed institutions<p>It’s just over a year since the <a href="https://theconversation.com/rethinking-youth-justice-there-are-alternatives-to-juvenile-detention-63329">Don Dale scandal</a> became public. A youth was <a href="http://www.abc.net.au/4corners/stories/2016/07/25/4504895.htm">shown on ABC 4Corners</a> bound and in a spit mask. Within a few hours, a <a href="https://childdetentionnt.royalcommission.gov.au/Pages/default.aspx">royal commission</a> was initiated, and within days the Northern Territory centre was to be condemned. </p>
<p>Now the brief is out for a new centre – but word is, <a href="http://architectureau.com/articles/design-brief-for-new-darwin-youth-detention-centre-slammed/?utm_source=ArchitectureAU&amp;utm_campaign=ec0c99a5cc-AAU_2017_07_12&amp;utm_medium=email&amp;utm_term=0_e3604e2a4a-ec0c99a5cc-41314117&amp;mc_cid=ec0c99a5cc&amp;mc_eid=00d901f802">it’s “a disgrace”</a>.</p>
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<figcaption><span class="caption">An excerpt from the 4Corners report, Australia’s Shame, on July 26 2016.</span></figcaption>
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<p>An obsession with “function” – the patterns and protocols of management and care – dominates the designs of residential institutions that serve unwilling guests, such as prisons, detention centres and mental health facilities. The functional spaces assume people’s behaviour will remain the same regardless of the architecture. And so residential institutions end up as places where the business of managing people should be easy.</p>
<p>But people aren’t easy. When forced into an institutional residential setting, they come with baggage that can’t be checked in at the sally port (the gate). </p>
<p>The clients are products of diverse cultures, they have kin, they may have addictions and special needs. Some will be prone to <a href="http://strona.app.nazwa.pl/uploads/images/2014_16_4/5Golembiewski_ArchivesPP_4_2014.pdf">aggression or at risk of suicide</a> (or both). In Australia, about half have <a href="http://www.aihw.gov.au/prisoner-health/mental-health/">mental illness</a>.</p>
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<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/good-mental-health-care-in-prisons-must-begin-and-end-in-the-community-40011">Good mental health care in prisons must begin and end in the community</a></em></p>
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<p>Much of the functional planning is designed to control this diversity and unruliness. But people generally don’t like to be controlled, especially if it means they can’t be with the people they love or contribute meaningfully to society. It’s hardly a surprise that facilities see bursts of violence.</p>
<h2>Tougher controls add to pressures</h2>
<p>If ever there’s an unplanned event with lasting consequences, the architecture is usually patched to prevent another similar event. This is usually very literal, such as putting in a layer of vandal-proof glass, CCTV, or some other invasive security measure. </p>
<p>These modifications rarely help, because they only intensify resentments and feelings of being controlled. Before too long, another incident is inevitable. </p>
<p>The final blow for a facility is usually when the public hears of an incident – <a href="http://www.abc.net.au/news/2014-08-25/don-dale-detainees-to-be-housed-at-mental-health-facility/5694616">the Don Dale Youth Detention Centre</a> and <a href="http://www.theage.com.au/victoria/half-of-parkville-youth-detention-centre-closed-because-of-rioting-20170109-gtobl4.html">Parkville Youth Justice Centre</a> in Victoria are recent cases in point. Remember, these are places that <em>unnecessarily</em> separate people from their loved ones and everything of importance – is an angry response really a surprise?</p>
<p>When a centre is being shut down, administrators frequently blame architecture: they say “it wasn’t fit for purpose”. Suddenly it’s the building that’s done wrong, not the people or protocols that gradually developed in it.</p>
<p>But the administrators may be right. <a href="https://theconversation.com/building-a-better-world-can-architecture-shape-behaviour-21541">Architecture can be very manipulative</a>; it can affect our behaviour and the choices we make. So why don’t designers anticipate behavioural problems when they’re designing a facility?</p>
<p>These problems arise because <em>as vulnerability increases, choice decreases</em>. When people are mentally ill, feel they’re oppressed, are emotionally overwrought or physically ill, their <a href="https://www.ncbi.nlm.nih.gov/pubmed/26597102">brains begin to function differently</a>. Their capacity to choose how to react to any given circumstances is reduced to a set of learned and instinctive behaviours, however inappropriate these are to those circumstances. </p>
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<figcaption><span class="caption">In oppressive conditions, peope’s capacity to choose how to react to any given circumstances is greatly reduced, however inappropriate their behaviour might be.</span></figcaption>
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<p>Importantly, this same effect reduces the possibility of behavioural change and reform, which is meant to be the focus of the <em>corrections</em> system. And only this past week, this was revealed to be a <a href="https://ipa.org.au/publications-ipa/research-papers/ipa-research-finds-australia-falling-behind-world-criminal-justice-costs-results-2">serious and costly problem</a> for criminal justice in Australia.</p>
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<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/the-state-of-imprisonment-in-australia-its-time-to-take-stock-38902">The state of imprisonment in Australia: it’s time to take stock</a></em></p>
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<p>What’s worse is that <a href="http://www.urbandesignmentalhealth.com/journal2-psychosis.html">people with mental illness can become symptomatic</a> in bad environments. Only when people are in a state of robust mental health can they develop new, nuanced responses and adapt well to circumstances.</p>
<h2>There is a better way</h2>
<p>People who have studied this problem talk about congruency. It’s about “the good fit” between the person, their culture and the place: the physical layout, the things there are to do, the attitudes of staff, etc. </p>
<p>If the clients were all healthy, this wouldn’t be so important, because people can then adapt easily. But in mental health facilities all the clients have mental problems, and a high number in prisons too – whether diagnosed or not.</p>
<p>To provide for clients in residential institutional care, administrators first have to understand that all clients are vulnerable. Even if they’re tattooed and tough and might carry a shank knife; if they’re in a residential institution, they’re vulnerable.</p>
<p>It’s essential to treat humans with dignity. First up, that means that prison should never primarily be a punishment (it’s not meant to be under <a href="https://www.unodc.org/documents/justice-and-prison-reform/GA-RESOLUTION/E_ebook.pdf">current United Nations rules</a> either). </p>
<hr>
<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/prisons-policy-is-turning-australia-into-the-second-nation-of-captives-38842">Prisons policy is turning Australia into the second nation of captives</a></em></p>
<hr>
<p>But beyond just abiding by the rules, it’s essential to provide for a meaningful existence. Different people and different cultures find meaning in different places, and it can be hard to provide for everyone. But that’s no excuse not to try.</p>
<p>Some universal values provide meaning for just about everyone. These can be expressed by making provision for family and for meaningful activity such as gardening, art, music, sport and religious expression. </p>
<p>Other provisions must be geared to local cultures. <a href="http://www.waikatodhb.health.nz/assets/news/Improving-mental-health-in-prisons.pdf">Te Kauwhata</a>, a secure mental health facility in New Zealand, has places for Maori clients to carve wood, based on the understanding that this cultural activity is important enough that they are equipped with dangerous carving tools.</p>
<p><a href="http://architectureau.com/articles/west-kimberley-regional-prison/">A prison in the Kimberly</a> provides wide, open spaces that are close to kin, and prisoners have opportunities to personalise their spaces.</p>
<p>Very few clients will be there for life. To maintain the competencies needed in the real world, it’s essential to shift the locus of control from staff to the clients. For this reason, the institution should promote trade in wholesome goods.</p>
<p>People should be encouraged to cook for each other and themselves, to do their own cleaning and to develop workplace and cultural skills such as sports development or learning musical instruments.</p>
<p>Until these basic concepts are routine and the reflexes of management are to look at opportunities to improve wellbeing, rather than making facilities harder and more segregated, social problems will remain at the heart of one scandal after another.</p>
<p>Remember, all buildings speak to us on a psychological level – but the bad ones scream.</p>
<hr>
<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/from-expected-reoffender-to-trusted-neighbour-why-we-should-rethink-our-prisons-60114">From expected reoffender to trusted neighbour: why we should rethink our prisons</a></em></p><img src="https://counter.theconversation.com/content/81990/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Golembiewski does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Architecture can affect behaviour and the choices we make. The brief is out for a centre to replace the Don Dale facility, but word is, it's 'a disgrace'. We can do much better.Jan Golembiewski, Researcher, UNSWLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/735572017-03-08T09:19:45Z2017-03-08T09:19:45ZDelivering better maternal mental health care: a diagnosis<figure><img src="https://images.theconversation.com/files/158948/original/image-20170301-5492-1d9cxo3.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">Getting support.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/loving-hands-mothers-hand-holding-her-127196099?src=ols-XsdKc7vVysHzPM3Rsw-1-22">Shutterstock</a></span></figcaption></figure><p>Low mood and anxiety are something we all experience at various points in our lives. And the enormous changes that occur on becoming a new parent means it is a time when these symptoms are particularly common. Dealing with these issues is an important part of caring for new mothers and mothers-to-be. But we need to be wary of turning normal human emotions and experiences into medical diagnoses. </p>
<p>A staggering 81% of women who responded to a <a href="https://www.rcog.org.uk/globalassets/documents/patients/information/maternalmental-healthwomens-voices.pdf">survey</a> by the <a href="https://www.rcog.org.uk/en/">Royal College of Obstetricians and Gynaecologists</a> (RCOG) said they had experienced a maternal mental health problem. This high figure however was widely <a href="https://www.channel4.com/news/concerns-about-womens-mental-health">reported in the media</a> – but it is misleading. As the authors themselves recognised, the self-selecting nature of the survey meant that women with experiences of perinatal mental health problems were far more likely to respond.</p>
<p>There are dangers in reporting such high rates of mental health problems associated with childbirth, or in suggesting that a majority of women need the input of mental health services. An unintended consequence of such high figures is to deflect attention from those women who do require specialist care. It is vital to remember that perinatal mental illnesses, such as <a href="http://www.app-network.org">postpartum psychosis</a>, can be some of the most severe episodes dealt with by mental health services.</p>
<p>We walk a tightrope here though. Because nor should we explain away distressing mental health symptoms as common, expected and what most women experience. The survey found that some women felt their symptoms were not being taken seriously and that they were told it was normal to feel down after having a baby. A related issue is that many women who experienced anxiety or other conditions felt that their symptoms were ignored or not treated seriously enough because they did not fit into the category of postnatal depression (PND). There are many and varied mental health conditions that can occur in pregnancy and the postpartum period – and there are dangers if all are labelled under the catch all category of PND. </p>
<p>But there are positive aspects to the report’s publication. First, whatever the content, the fact that it has come from the Royal College of Obstetricians and Gynaecologists is in itself important and encouraging. As highlighted by the <a href="http://maternalmentalhealthalliance.org/">Maternal Mental Health Alliance</a> campaign, this issue is “<a href="http://everyonesbusiness.org.uk">everyone’s business</a>”. </p>
<p>Although specialist perinatal mental health teams are vital, the mental health of mothers should not be the concern of psychiatric services alone. All health care professionals who come into contact with women in the perinatal period should address both their mental and physical health. Although 85% of women reported that they were asked about their mental health, some felt that through pregnancy and the postpartum only their physical symptoms were assessed and treated.</p>
<p>In maternity services we see no better illustration of the need for “<a href="https://www.rcpsych.ac.uk/pdf/Parity%20of%20Esteem%20briefing%20Feb%202012.pdf">parity of esteem</a>” between mental and physical health. As a society we rightly spend large amounts of time and money ensuring the physical health of mothers and their babies. By comparison, we devote a tiny fraction of this effort and expense to a woman’s mental health. It is incredible that women in around half the UK (including most of Scotland, Wales and Northern Ireland and many parts of England) <a href="http://everyonesbusiness.org.uk/?page_id=349%5D">still have no access</a> to specialist perinatal community mental health teams.</p>
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<span class="caption">Little bundles of mixed emotions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-cute-babies-on-light-background-334090796?src=BZawPy5WReyvchvht8BBrg-2-26">Shutterstock</a></span>
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<p>Secondly, through this survey we hear from those with personal experience of perinatal mental illness. Theirs is a powerful voice. It is clear to me, having researched and worked in this area for many years, that those in power do not only want to hear from clinicians and academics (if indeed they want to hear from us at all). The individual stories of those who have experienced perinatal mental illness give a human face to the messages emerging from research. The success of the “<a href="http://everyonesbusiness.org.uk">everyone’s business</a>” campaign has in no small part been due to putting the voice of women and their partners front and centre.</p>
<h2>A mother’s work</h2>
<p>Third, there are a number of very clear and important messages from the women who participated. For example, of the women who reported mental health problems it is a concern that the majority were not referred on to services or given any advice about organisations to contact for further help. More disturbingly perhaps, among women who had pre-existing mental health problems, many reported no consensus from health care professionals on whether to stop, reduce, change or continue with medication, with some describing open disagreements within the health care team. </p>
<p>Although there are undoubtedly examples of world leading perinatal mental health care in the UK, the survey revealed an unacceptably wide variation, with little evidence of the universal delivery of evidence based care on the basis of need rather than postcode. </p>
<p>We know the need. We know what to do – and it is clear that this issue does not benefit from a “one size fits all” approach. We need universal and specialist services that enable the right level of support and treatment to be delivered to the right woman at the right time – no matter what her mental health condition or where she lives. With extra funding for perinatal mental health services being delivered in some parts of the UK we are moving in the right direction. There clearly remains, however, some distance to go.</p><img src="https://counter.theconversation.com/content/73557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Jones is a Profeesor of psychiatry at Cardiff university and a perinatal psychiatrist
He is Director of the National Centre for Mental Health (NCMH)
He is a trustee and past Chair of Action on Postpartum Psychosis
He is affiliated with the Maternal Mental Health Alliance and Chairs the Campaign Working Group of the Comic Relief funded Everyone,s Business Campaign </span></em></p>Many women are not getting the right kind of attention.Ian Jones, Professor of Psychiatry, Director of National Centre for Mental Health, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/724722017-02-06T12:34:09Z2017-02-06T12:34:09ZPatient deaths show South Africa's care for the mentally ill is in disarray<figure><img src="https://images.theconversation.com/files/155612/original/image-20170206-18271-1ialc7l.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Emanuele Mazzoni Photo/Shutterstock</span></span></figcaption></figure><p><em>A report in South Africa detailing <a href="https://theconversation.com/politicians-must-account-for-the-deaths-of-94-psychiatric-patients-in-south-africa-72422">the death of 94 people</a> with mental health disorders who were moved from the Life Esidemeni Hospital and placed in inadequate facilities has sparked outrage and led to Qedani Mahlangu stepping down as the local government Minister of Health in Gauteng province. Janine Bezuidenhout and Shehnaz Munshi unpack <a href="http://www.ohsc.org.za/images/documents/FINALREPORT.pdf">the report</a> and what it reveals about mental health care in South Africa.</em></p>
<p><strong>What did the report find and what does this say about the system failures in mental health care?</strong></p>
<p>Generally people with mental health disorders have limited access to the <a href="http://www.who.int/mental_health/evidence/south_africa_who_aims_report.pdf">appropriate health care services</a>. They have a lower life-expectancy and the increased risk of co-morbid physical illnesses. It is critical for them to have a stable environment, with qualified medical professionals. </p>
<p>The health ombudsman’s report was damning. It found that 94 patients – and not 36 as previously reported – died after they were moved from the hospital to facilities run by NGOs.</p>
<p>In total 1,039 patients were transferred to 27 NGOs. The reported deaths occurred in 16 of the 27. None had the appropriate license to take care of the patients.</p>
<p>The report’s most damning findings are around the:</p>
<p><strong>Transfer of patients:</strong> Patients were moved without their families being informed. Some incapacitated patients without wheelchairs were tied with bed sheets to support them. Others were transported in open trucks.</p>
<p>Patients ended up in organisations not originally selected for them or far away from the families. Some patients with co-morbid medical conditions, which requires specialised medical care, were transferred to facilities where no such care was available.</p>
<p><strong>NGO conditions:</strong> The organisations were not sustainable. They did not have financial support for infrastructure, food, clothing and bedding for the winter months. As a result some had no bedding or blankets and others left patients hungry. Many patients were malnourished and suffered severe weight loss.</p>
<p>In addition, staff were not trained or prepared for the task of taking care of the patients. Overcrowding was common and some patients were left dirty, poorly groomed and without treatment. Some weren’t given the correct medication which meant that they were at a higher risk of relapsing.</p>
<p>Fourteen of the 25 inspected NGOs were found not fit for purpose. The recommendation is that they should be closed.</p>
<p><strong>Causes of death:</strong> A sample of 38 patients were selected to determine their cause of death. In 21 of the 38 patients, the immediate cause of death could be identified. For those, most died of pneumonia, uncontrolled epilepsy, stroke, sepsis or dehydration.</p>
<p>Families were not immediately notified of deaths. Some families only found out three weeks later.</p>
<p><strong>What does the report tell us about the bigger picture of mental health care failings in South Africa?</strong></p>
<p>The report shows that mental health care in South Africa is in a state of disarray. </p>
<p>South Africa has good policies for mental health care. But the implementation of these policies remain a challenge. Mental health services have not been integrated into the routine care of chronic diseases and within the primary health care system. As a result mental health has been <a href="https://www.health-e.org.za/wp-content/uploads/2016/05/South-African-Health-Review-2016.pdf">marginalised and underfunded</a>. </p>
<p>There are several areas that create <a href="http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf">barriers</a> to effective mental health care services. These include: </p>
<ul>
<li><p>A lack of financial investment: without the financial resources invested in mental health, programmes will <a href="https://www.health-e.org.za/wp-content/uploads/2016/05/South-African-Health-Review-2016.pdf">not be sustained</a>. This is despite the fact that studies show that it costs more <a href="https://www.health-e.org.za/wp-content/uploads/2016/05/South-African-Health-Review-2016.pdf">not to treat mental disorders</a> than to treat it.</p></li>
<li><p>Stock outs of medications: According to the <a href="https://www.health-e.org.za/wp-content/uploads/2015/10/rural-mental-health-campaign-report-2015.pdf">stop stock-outs project</a>, psychiatric medication made up 10% of the reported medication stock outs in the country between January and July 2015. </p></li>
<li><p>The social stigma associated with mental disorders</p></li>
</ul>
<p><strong>Does mental health care play second fiddle to primary health care in the country?</strong></p>
<p>Mental health care has always been the “stepchild” of health care. In South Africa, it is estimated that 75% of people with a mental health disorder don’t receive mental health care services. This is referred to as the “mental health treatment gap”.</p>
<p><a href="http://bjp.rcpsych.org/content/208/s56/s29">Integrating mental health care</a> into the existing health system structures could reduce the stigma and result in greater effectiveness of health care interventions. </p>
<p>There are moves to incorporate mental health care better. Recent policies by the National Department of Health show a high level of commitment to integrate mental health care services into the primary health care chain.</p>
<p>The department’s <a href="https://www.health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">2013-2020 mental health policy framework and strategic plan</a> envisages scaling up and decentralising integrated primary mental health services. This includes community-based care, primary health care and district hospital level care. Implementing and sustaining these policies are key. </p>
<p>In the long term health plan under the National Health Insurance (NHI), mental health care appears to be sidelined. In the white paper on the NHI, mental health care is only broadly mentioned. Mental health services are included as part of the comprehensive package, but no detail is provided about programmes, or how the shortage of mental health professionals will be addressed. </p>
<p><strong>What next? What steps should be taken to avoid this from happening again?</strong></p>
<p>Five of the NGOs have already been closed down. The ombudsman recommended that remedial action should be implemented within 45 days of the release of the report. </p>
<p>The report needs to be studied in detail to establish which key actions should be taken to prevent this from happening again. </p>
<p>The report, combined with existing policies, should be used to put a plan in place for mental health care services. This was proposed by the social justice NGO <a href="http://www.huffingtonpost.co.za/2017/02/01/the-life-esidimeni-deaths-explained/">Section27</a>.</p>
<p>There also needs to be more transparency and accountability within the Department of Health. It was repeatedly warned that the transfer was placing patients in danger. The department was <a href="http://www.huffingtonpost.co.za/2017/02/01/the-life-esidimeni-deaths-explained/">taken to court twice</a>. It assured the court that the patients’ health would not be compromised by the transfers. Its actions resulted in human rights violations as well as medical negligence.</p>
<p>Opposition parties have called for legal action. The Economic Freedom Fighters have <a href="http://citizen.co.za/news/news-national/1417575/da-lays-culpable-homicide-charge-qedani-mahlangu/">laid charges</a> of murder against the former local government minister and the Democratic Alliance of culpable homicide and contravening the Mental Health Care Act and the National Health Act. Several organisations involved in the tragedy are considering similar action. All believe that those responsible should be held <a href="http://section27.org.za/2017/02/section27-calls-for-systematic-change-in-mental-health-in-south-africa/">legally accountable</a>. </p>
<p><em>Janine Bezuidenhoudt co-authored this article. She works for the Foundation of Professional Development.</em></p><img src="https://counter.theconversation.com/content/72472/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shehnaz Munshi is affiliated with the Junior Public Health Association of South Africa and the People&#39;s Health Movement - South Africa (PHM-SA). </span></em></p>The 94 people with mental health disorders who died after they were moved from the Life Esidemeni facility and put into inadequate care shows the poor state of mental health care in South Africa.Shehnaz Munshi, Occupational Therapist, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/677442016-10-31T11:25:27Z2016-10-31T11:25:27ZInstitutionalised and raped: Moldova turns shocking case into bold example of justice for vulnerable victims<figure><img src="https://images.theconversation.com/files/143661/original/image-20161028-15783-17oil5f.jpg?ixlib=rb-1.1.0&amp;rect=5%2C1101%2C1994%2C1242&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>A trial court in Bălți, a town in the small eastern European country of Moldova, recently found 50-year-old Stanislav Florea <a href="http://crimemoldova.com/news/kriminal/medicul-nvinuit-c-a-violat-16-paciente-de-la-internatul-psihoneurologic-a-fost-condamnat-la-13-ani-d/">guilty</a> of raping 16 women over a period of more than a decade. The court sentenced him to 13 years’ imprisonment. </p>
<p>Moldova – which has a population of 3.5m – is <a href="http://www.worldbank.org/en/country/moldova/overview">Europe’s poorest country</a>. This trial has been particularly shocking because Florea was the psychiatrist in charge of the 400-bed social care institution in Bălți. His victims were female residents with mental health issues or other disabilities. </p>
<p>The conviction is important as it is the first of its kind in central and eastern Europe, where I have been working for 15 years. Over that time, I’ve heard about countless incidents of sexual violence in mental health institutions. It’s also important as an example of how people with particular needs are, and should, be treated by courts the world over.</p>
<p>The trial was fraught with difficulties. Instead of helping them, prosecutors scoffed at and berated the women. A human rights lawyer was deployed to help the women and get the prosecutor – and in turn the judges – to take them seriously. To their credit, the three trial judges listened to women labelled with mental health difficulties whose testimonies were at risk of being dismissed. The women were eventually taken seriously and the verdict verifies their version of what took place behind closed doors.</p>
<p>History tells us that detention breeds exploitation, violence and abuse. This is especially true when, as is the situation in Moldova, there is no independent and regular system of inspection. Florea was able to continue attack these women for such a long time because of the power he held as their doctor and as a respected member of the community. He used his power to threaten the women with seclusion and injecting them with large doses of neuroleptic medication. </p>
<h2>Global attention</h2>
<p>Earlier this year the UN Committee on the Rights of Persons with Disabilities issued a “<a href="http://www.ohchr.org/Documents/HRBodies/CRPD/GC/Women/CRPD-C-GC-3.doc">general comment</a>” on women and girls with disabilities. This document states that because of “stereotyping based on the intersection of gender and disability, women with disabilities may face barriers when reporting violence, such as disbelief and dismissal by police, prosecutors and courts”.</p>
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<a href="https://images.theconversation.com/files/143666/original/image-20161028-15816-pykzs6.JPG?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=1000&amp;fit=clip"><img alt="" src="https://images.theconversation.com/files/143666/original/image-20161028-15816-pykzs6.JPG?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=237&amp;fit=clip"></a>
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<span class="caption">The Bălți institution.</span>
<span class="attribution"><span class="source">Oliver Lewis</span>, <span class="license">Author provided</span></span>
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<p>Yet women with disabilities are <a href="http://fra.europa.eu/sites/default/files/fra-2014-vaw-survey-main-results-apr14_en.pdf">more likely</a> to become victims of violence. Three years ago the <a href="http://www.mdac.org">Mental Disability Advocacy Centre (MDAC)</a>, an international human rights charity that I run, sent information on Moldova to the <a href="http://www.ohchr.org/en/hrbodies/cedaw/pages/cedawindex.aspx">UN women’s rights committee</a>. The resulting <a href="http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fMDA%2fCO%2f4-5&amp;Lang=en">report</a> called on the Moldovan government to investigate all cases of sexual assault against women with disabilities in residential institutions. </p>
<p>The Moldova conviction illustrates how justice systems can – when they are under the spotlight – take into account the testimonies of women who the law has otherwise labelled as incompetent. </p>
<p>Victims of gender-based violence need to be offered specific psychological support to deal with trauma, potentially including treatment for <a href="http://www.aaets.org/article178.htm">post-traumatic stress disorder</a>. </p>
<p>The victims in this case were also institutionalised and had disabilities. Another complicating factor was that a public institution had breached their trust. In small and resource poor countries such as Moldova, there are few professionals up to the job of investigating.</p>
<h2>Closing institutions</h2>
<p>The Moldova case also highlights another disturbing problem. In order to reduce the likelihood of abuse like this happening, the Moldovan government is being called upon to get rid of the kind of institution that Florea ran – those that keep people with mental health issues locked up, away from the rest of the world.</p>
<p>In Moldova there are 2,200 people who are forced to live in <a href="http://mdac.org/en/olivertalks/2013/10/30/girls-and-women-disabilities-have-rights-too">13 psychiatric and social care institutions</a>. Across Europe there are no reliable data, but there are believed to be well over one million people languishing in institutions of this kind.</p>
<p>These establishments hark back to a bygone age when it was considered acceptable to warehouse people labelled as “mad” or “incompetent” to live their lives out of sight and out of mind. Segregation of people with disabilities is no longer acceptable anywhere in the world, and the global trend is to <a href="https://wcd.coe.int/ViewDoc.jsp?p=&amp;id=1917847&amp;direct=true">shift people out of institutions and into the community</a> with the support they need to flourish. Budgetary flexibility, policy reform and local leadership are all needed to create alternatives that work in any context. </p>
<p>Community living is not just a nicety – it is an enforceable right. The <a href="http://www.un.org/disabilities/convention/conventionfull.shtml">UN Convention on the Rights of Persons with Disabilities</a> is binding on Moldova, as it is on <a href="http://www.ohchr.org/Documents/HRBodies/CRPD/OHCHR_Map_CRPD.pdf">most countries</a>. The Convention requires governments to implement the right to live independently and be included in the community with the benefit of individualised services designed to prevent segregation and isolation.</p>
<p>The conviction of a serial rapist in Moldova has highlighted the horrors of sexual violence against women with disabilities, but has also reminded us about the consequences of institutionalisation. The women of Bălți may have had justice in the courtroom, but they also deserve inclusion in the community.</p><img src="https://counter.theconversation.com/content/67744/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oliver Lewis is the Executive Director of the Mental Disability Advocacy Centre, an NGO mentioned in the article. </span></em></p>A doctor has been convicted of abusing vulnerable women in his care – because a court finally decided to listen to their stories.Oliver Lewis, Professor of Law and Social Justice, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/664452016-10-05T19:24:12Z2016-10-05T19:24:12ZWhy South Africa is failing mental health patients and what can be done about it<figure><img src="https://images.theconversation.com/files/140471/original/image-20161005-14219-1i8u1sr.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Health authorities in South Africa’s wealthiest province, Gauteng, have launched an investigation into the deaths of <a href="http://ewn.co.za/2016/10/02/Yet-another-Life-Esidimeni-psychiatric-patient-dies">37 people with chronic mental illness who died</a> over a four-month period. The patients were part of a group of 1300 relocated from a mental health facility last December. Janine Bezuidenhoudt explains why mental health is still neglected in developing countries. South Africa is no exception.</em></p>
<p><strong>There has been increased attention given to mental health as a global priority. Has the management of mental health changed as a result, particularly in developing countries?</strong> </p>
<p>Developing countries have unique challenges which either lead to or worsen mental health disorders. These include people experiencing trauma, injury, violence as well as the burden of infectious diseases, harsh economic circumstances and poor living conditions.</p>
<p>Depression is one of the most common mental health disorders in the world. According to the World Health Organisation more than <a href="http://www.who.int/mediacentre/factsheets/fs369/en/">350 million people suffer</a> from the condition globally.</p>
<p>But mental health care takes the backseat when it comes to the allocation of resources. This is due to the burden of infectious and non-communicable diseases which are given priority. </p>
<p>Yet, in developing countries, mental health should be given the same priority. Neuropsychiatric disorders – which include mental health and nervous system disorders – are the <a href="http://www.samj.org.za/index.php/samj/article/view/830/296">third largest contributor</a> to the burden of disease after HIV/AIDS and other infectious diseases.</p>
<p>Another problem is that although policies have been developed for mental health care, implementation remains a challenge. This means that the management of mental health care in developing countries has not changed. </p>
<p><strong>How does South Africa treat its mentally ill?</strong></p>
<p>South Africa has a history of being unkind to its vulnerable populations. This includes those who have mental disorders. In terms of policies the situation has improved quite a bit in the last decade. Several are now in place to take care of people with a mental health conditions. These include:</p>
<ul>
<li><p><a href="https://www.health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">The National Mental Health Policy Framework and Strategic Plan</a></p></li>
<li><p><a href="http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/legislations/acts/mental_health_care_act_17_of_2002.pdf">The Mental Health Care Act</a></p></li>
<li><p><a href="http://www.gov.za/sites/www.gov.za/files/39792_gon230.pdf">White Paper on the rights of people with disabilities</a></p></li>
</ul>
<p>These policies aim to ensure that people with disabilities enjoy the same rights as their fellow citizens and that all citizens and institutions share equal responsibility for building such a society.</p>
<p>But policies alone are not good enough, especially if they’re not enforced and there is no accountability. </p>
<p>There are a number of instances that illustrate the fact that policies aren’t yet having the desired effect. Possibly the most stark was the recent death of 37 patients over a four-month period.</p>
<p>A total of 1300 mental health patients were transferred from a mental health facility, the Life Esidimeni Healthcare Centre, to non-governmental organisations. Several organisations, including the <a href="http://www.sadag.org/">South African Depression and Anxiety Group </a>, <a href="http://www.psyssa.com/">Psychological Society of SA</a>, human rights group <a href="http://section27.org.za/">Section27</a> and the <a href="http://www.safmh.org.za/">South African Federation for Mental Health</a> <a href="http://www.dailymaverick.co.za/article/2016-09-15-life-esidimeni-families-of-mentally-ill-patients-blame-mec-for-deaths/#.V_On7fB97IU">warned</a> against the move. </p>
<p>But the government went ahead and transferred patients to organisations that were not equipped to manage and care for them. The deaths were shocking. And there are still concerns about the quality of care and living conditions for the rest of the patients.</p>
<p><strong>What particular challenges does South Africa have?</strong></p>
<p>Mental health care is underfunded and under-resourced. </p>
<p>There are are not enough trained mental health professionals. In 2010, South Africa had <a href="http://www.who.int/bulletin/volumes/89/3/BLT-10-082784-table-T3.html">1.58 psychosocial providers</a> for every 100,000 people. In the same period, Argentina had <a href="http://www.who.int/bulletin/volumes/89/3/BLT-10-082784-table-T3.html">13.19 psychosocial providers</a> for every 100,000 people. The World Health Organisation <a href="http://www.who.int/bulletin/volumes/89/3/10-082784/en/">recommends</a> that South Africa increase its psychosocial professionals by <a href="http://www.who.int/bulletin/volumes/89/3/BLT-10-082784-table-T3.html">2937</a>.</p>
<p>There has been a heavy reliance on psychiatric hospitals to care for and manage mentally ill patients. But public sector mental health care services are not accessible to the country’s most vulnerable populations. The hospitals also don’t have enough trained mental health professionals.</p>
<p>This means there is a large treatment gap. About 75% of people with mental health illness do not access mental health care. </p>
<p>In addition to this Western psychological models are used. These are not representative of the South African population. South Africa’s high prevalence of HIV/AIDS and TB means that specific mental health screening tools and treatment care models need to be developed. And the country isn’t using indigenous knowledge systems for primary prevention, such as making use of traditional healers.</p>
<p>More generally, mental health care management and treatment is not integrated into other health care programmes.</p>
<p>People with mental health illnesses are also often discriminated against and are stigmatised. This means they don’t access the health care they need. If they do they often fail to get the quality of care they need.</p>
<p><strong>What needs to be done?</strong></p>
<p>Mental health care management and services need to made a priority. And mental health care must be de-institutionalised so that community-based care can be set up in a systematic way. This would entail first strengthening and then expanding community-based care. </p>
<p>Mental health screening must also be integrated with care and management at primary care level – especially for people who have TB, are living with HIV or AIDS, are pregnant or who recently gave birth.</p>
<p>The country should also develop indicators to ensure the provision of quality mental health care management and services. These indicators must be monitored and evaluated.</p>
<p>Human resources also need to be tackled. This needs to happen at a number of levels. At the health care professional level, all should be trained on how to manage mental health disorders. At the management level, managers need to be trained in mental health management, care and treatment to ensure mental health care is treated as an essential part of health care delivery. It should be integrated into routine health care delivery.
Mental health care management should not be a specialist field. It should be introduced into the <a href="http://psytalk.psyssa.com/mental-health-norwegian-schools-one-book-missing/">broader curriculum for students</a> and covered as routine care management for health care workers.</p><img src="https://counter.theconversation.com/content/66445/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janine Bezuidenhoudt is affiliated with the Junior Public Health Association of South Africa (JuPHASA) as well as the SA-People&#39;s Health Movement (SA-PHM). Also work with the Treatment Action Campaign (TAC) and the Psychological Society of SA - Student Division (PsySSA_SD). </span></em></p>In developing countries mental health care generally takes a backseat when it comes to allocating resources.Janine Bezuidenhoudt, Research co-ordinator, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/652512016-09-25T19:30:36Z2016-09-25T19:30:36ZThe science is in: gardening is good for you<figure><img src="https://images.theconversation.com/files/138166/original/image-20160919-17029-2dn60d.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">Time spent weeding, potting and pruning can be as good for the gardener as it is for the garden.</span> <span class="attribution"><span class="source">Image from www.shutterstock.com</span></span></figcaption></figure><p><em>As the weather warms and days lengthen, your attention may be turning to that forgotten patch of your backyard. This week we’ve asked our experts to share the science behind gardening. So grab a trowel and your green thumbs, and dig in.</em></p>
<hr>
<p>“That’s all very well put,” says Candide, in the final line of Voltaire’s novel of the same name, “but we must go and work our garden.”</p>
<p>I studied this text at high school before I became a gardener and professional horticulturist. We were taught that Candide’s gardening imperative was metaphorical not literal; a command for finding an authentic vocation, not a call to take up trowels and secateurs. </p>
<p>In fact, Voltaire himself really believed that active gardening was a great way to stay sane, healthy and free from stress. That was 300 years ago.</p>
<p>As it turns out, the science suggests he was right.</p>
<h2>The science of therapeutic horticulture</h2>
<p>Gardens and landscapes have long been designed as sanctuaries and retreats from the stresses of life – from great urban green spaces such as Central Park in New York to the humblest suburban backyard. But beyond the passive enjoyment of a garden or of being in nature more generally, researchers have also studied the role of actively caring for plants as a therapeutic and educational tool.</p>
<p>“Therapeutic horticulture” and “horticultural therapy” have become recognised treatments for stress and depression, which have served as a healing aid in settings ranging from prisons and mental health treatment facilities to schools and hospitals. </p>
<h2>Gardening and school</h2>
<p>Studies of school gardening programs – which usually centre on growing food – show that students who have worked on designing, creating and maintaining gardens develop more positive attitudes about health, nutrition and the <a href="http://www.kohalacenter.org/HISGN/pdf/HPP_2011_MMR_Sample1.pdf">consumption</a> of <a href="http://search.proquest.com/openview/61a8bb123ec000d6a6348aeb950645fa/1?pq-origsite=gscholar">vegetables</a>.</p>
<p>They also <a href="http://horttech.ashspublications.org/content/15/3/439.short">score better</a> on science <a href="http://aggie-horticulture.tamu.edu/syllabi/435/Articles/Klemmer.pdf">achievement</a>, have better attitudes about school, and improve their <a href="http://www.tandfonline.com/doi/abs/10.1080/15330150701318828">interpersonal skills</a> and <a href="https://food-hub.org/files/resources/Blair_The%20Child%20in%20the%20Garden_J.%20Environ%20Educ_2009.pdf">classroom behaviour</a>. </p>
<p>Research on students confirms that gardening leads to higher levels of self-esteem and responsibility. Research suggests that incorporating gardening into a <a href="http://kohalacenter.org/HISGN/pdf/Thechildinthegarden.pdf">school setting</a> can boost group cohesiveness.</p>
<h2>Gardening and mental health</h2>
<p>Tailored gardening programs have been shown to increase quality of life for people with <a href="http://www.tandfonline.com/doi/abs/10.1300/J004v16n01_02">chronic mental illnesses</a>, including <a href="http://www.tandfonline.com/doi/abs/10.1300/J004v16n01_02">anxiety and depression</a>.</p>
<p>Another study on the use of therapeutic horticulture for patients with clinical depression sought to understand why gardening programs were effective in lessening patient experience of depression. They found that structured gardening activities gave patients existential purpose. Put simply, it <a href="http://www.tandfonline.com/doi/abs/10.3109/01612840.2010.528168">gave their lives meaning</a>.</p>
<p>In jails and corrective programs, horticultural therapy programs have been used to give inmates positive, purposeful activities that lessen aggression and hostility during and after incarceration. </p>
<p>In one detailed study from a San Francisco program, involvement in therapeutic horticulture was particularly effective in <a href="http://www.tandfonline.com/doi/abs/10.1300/J076v26n03_10">improving psychosocial functioning</a> across prison populations (although the benefits were not necessarily sustained after release.)</p>
<p>Gardening has been shown to help improve the lives of <a href="https://www.researchgate.net/profile/Jacqueline_Atkinson/publication/265575473_AN_EVALUATION_OF_THE_GARDENING_LEAVE_PROJECT_FOR_EX-MILITARY_PERSONNEL_WITH_PTSD_AND_OTHER_COMBAT_RELATED_MENTAL_HEALTH_PROBLEMS/links/55094b960cf26ff55f852b50.pdf">military veterans</a> and <a href="http://www.joe.org/joe/2007june/iw5p.shtml">homeless people</a>. Various therapeutic horticulture <a href="https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/2930">programs</a> have been used to help people with learning difficulties, asylum seekers, refugees and victims of torture.</p>
<h2>Gardening and older people</h2>
<p>As populations in the West age, hands-on gardening programs have been used for older people in nursing homes and related facilities. </p>
<p>A systematic review of 22 studies of gardening programs for older adults found that gardening was a powerful <a href="http://www.tandfonline.com/doi/abs/10.1080/01924788.2013.784942">health-promoting activity</a> across diverse populations.</p>
<p>One <a href="http://journals.lww.com/jcrjournal/Abstract/2005/09000/Effects_of_Horticultural_Therapy_on_Mood_and_Heart.8.aspx">study</a> sought to understand if patients recovering from heart attack might benefit from a horticultural therapy program. It concluded:</p>
<blockquote>
<p>[Our] findings indicate that horticultural therapy improves mood state, suggesting that it may be a useful tool in reducing stress. Therefore, to the extent that stress contributes to coronary heart disease, these findings support the role of horticultural therapy as an effective component of cardiac rehabilitation.</p>
</blockquote>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Yvir4sm2G7Q?wmode=transparent&amp;start=0" frameborder="0" allowfullscreen></iframe>
<figcaption><span class="caption">Horticulturist and nurse Steven Wells talks about his work at Austin Health.</span></figcaption>
</figure>
<p>While the literature on the positive effects of gardening, reflecting both qualitative and quantitative studies, is large, most of these studies are from overseas. </p>
<p>Investment in horticultural therapy programs in Australia is piecemeal. That said, there are some standout success stories such as the <a href="https://www.kitchengardenfoundation.org.au/">Stephanie Alexander Kitchen Garden Foundation</a> and the work of nurse <a href="https://www.anmfvic.asn.au/membership/member-profiles/steven-wells">Steven Wells at the Royal Talbot Rehabilitation Centre</a> and beyond.</p>
<p>Finally, without professionally trained horticulturists none of these programs – in Australia or internationally – can take place.</p><img src="https://counter.theconversation.com/content/65251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Williams does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A growing body of research literature suggests time spent gardening is as good for the gardener as it is for the garden.Chris Williams, Lecturer in urban horticulture, University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/446422015-07-27T10:03:36Z2015-07-27T10:03:36ZHow the legacy of slavery affects the mental health of black Americans today<p>On July 22, in announcing the federal indictment of Charleston killer Dylann Roof, Attorney General Loretta Lynch <a href="http://www.postandcourier.com/article/20150722/PC16/150729789">commented</a> that the expression of forgiveness offered by the victims’ families is “an incredible lesson and message for us all.” </p>
<p>Forgiveness and grace are, indeed, hallmarks of the Black Church. </p>
<p>Since slavery, the church has been a formidable force for the survival of blacks in an America still grappling with the residual effects of white supremacy. </p>
<p>This was eloquently illustrated in the aftermath of the Charleston church massacre. Americans rightly stood in awe of the bereaved families’ laudable demonstration of God’s grace in action. </p>
<p>But what about the psychic toll that these acts of forgiveness exact? </p>
<p>Events like Charleston put a spotlight on the growing body of literature that looks not only at the United States’ failure to have authentic conversations about slavery and its legacy but also at the mental health impact of forgiving
acts of white racism and repressing justifiable feelings of anger and outrage – whether these are <a href="http://www.csmonitor.com/USA/USA-Update/2015/0724/Why-is-Dylann-Roof-not-facing-charges-of-terrorism">horrific acts</a> of <a href="https://www.fbi.gov/about-us/investigate/terrorism/terrorism-definition">terrorism</a> or nuanced <a href="http://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-987">microaggressions.</a> </p>
<p>I am a social work educator and practitioner with 25 years of experience in the field of mental health. I teach at one of the nation’s leading schools of social work, committed to preparing its graduates to work with racially and ethnically diverse populations. It is time, I believe, to bring this new field of inquiry into the mainstream. </p>
<h2>The church as buffer</h2>
<p>In his seminal book, <a href="http://ukcatalogue.oup.com/product/9780195161793.do">Mighty Like A River, the Black Church and Social Reform</a>, sociologist <a href="http://ifs.sc.edu/facultystaff/billingsley.asp">Andrew Billingsley</a> asserts that the Black Church is the only African-American institution that has not been reenvisioned in the image of whites. </p>
<p>His research illuminates the role of religion in building the resilience that allows blacks as a people to overcome the various forms of terrorism and oppression endured over centuries that sustain doctrines of white supremacy. </p>
<p>Indeed, in <a href="http://books.simonandschuster.com/Climbing-Jacobs-Ladder/Andrew-Billingsley/9780671677091">his analysis</a> of the African-American family, Billingsley concludes that it is “amazingly strong, enduring, adaptive and highly resilient.”</p>
<p>But as we pay homage to church and family in buffering blacks against the full effects of white racism, we must not obscure or diminish racism’s impact on the mental health that few blacks – <a href="http://www.nytimes.com/2011/08/11/books/excerpt-the-persistence-of-the-color-line.html?_r=0">irrespective of educational, social or economic status</a> – will escape. </p>
<p>There is increasing evidence that repressing feelings associated with acts of white racism may be psychologically damaging and lay the foundation for future mental health problems and behaviors symptomatic of post-traumatic stress syndrome.</p>
<h2>Evidence of racism’s impact on mental health</h2>
<p>Harvard psychiatrist Alvin Poussaint asked why suicide rates among black males doubled between 1980 and 1995. </p>
<p>In his co-authored book, <a href="http://www.beacon.org/Lay-My-Burden-Down-P155.aspx">Lay My Burden Down: Suicide and the Mental Health Crisis among African-Americans</a>, which takes its title from a <a href="https://www.youtube.com/watch?v=2LbzGjGUgGU">Negro spiritual</a> describing the hardships of the slave system, he argues that one of the reasons for this increase is that African-American young men may see the afterlife as a better place. </p>
<p><a href="http://terriewilliams.com/portfolio/home/terrie-williams-author/">Terrie M Williams</a> is a clinical social worker in New York. In her book, <a href="http://books.simonandschuster.com/Black-Pain/Terrie-M-Williams/9780743298834">Black Pain: It Just Looks Like We’re Not Hurting</a>, she uses powerful personal narratives of blacks from all walks of life to illustrate the high toll of hiding the pain associated with the black experience on mental health. </p>
<p>Joy DeGruy, Portland State University researcher and scholar, has developed “<a href="http://joydegruy.com/resources-2/post-traumatic-slave-syndrome/">post-traumatic slave syndrome</a>” as a theory for explaining the effects of unresolved trauma on the behaviors of blacks that is transmitted from generation to generation. </p>
<p>DeGruy’s argument may be <a href="http://www.essence.com/2005/01/12/breaking-the-chains">controversial</a>, but the questions she asked are surely relevant as we try to make sense, for example, of <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=2293169">research</a> released this July that shows suicide rates among black elementary school pupils significantly increasing between 1993 and 2012. </p>
<h2>Moving to the mainstream…slowly</h2>
<p>The fact is that from my perspective at New York University’s Silver School of Social Work, these publications have yet to move into mainstream literature. They have low visibility in the curricula and training programs for mental health professionals. </p>
<p>Nor have the questions these scholars and practitioners raised led to the kind of research that is <a href="https://www.omh.ny.gov/omhweb/cultural_competence/resources.html">needed</a> to support race-conscious and culturally appropriate practices for the mental health programs and agencies working with African-American families. </p>
<p>At the same time, however, the original thinking of authors like Poussaint and DeGruy is very much in sync with the new emphasis on <a href="http://www.socialworktoday.com/archive/exc_012014.shtml">trauma-informed care</a> in social work across all fields of practice. </p>
<p>As the Centers for Disease Control and Prevention concluded in a May 2014 <a href="http://www.cdc.gov/violenceprevention/acestudy/findings.html">research report</a>, undiagnosed childhood neglect or trauma is widespread among American adults and is the root cause of mental health and behavioral problems in adulthood. </p>
<p>Indeed, it is now the recommendation of the <a href="http://www.thenationalcouncil.org/topics/trauma-informed-care/">National Council for Behavioral Health</a> that trauma-informed care be integrated into all assessment and treatment procedures. </p>
<p>This emphasis on trauma provides a new lens for developing research into the impact of slavery - and its legacy of structural and institutional racism - on black mental health today.</p>
<h2>A difficult topic of conversation</h2>
<p>The problem is, no one likes to talk about slavery.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/89694/original/image-20150724-8468-1jac4aj.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=237&amp;fit=clip">
<figcaption>
<span class="caption">The trauma of slavery.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Slavery_in_the_United_States#/media/File:Cicatrices_de_flagellation_sur_un_esclave.jpg">National Archives and Records</a></span>
</figcaption>
</figure>
<p>For blacks descended from slaves, the subject evokes feelings of shame and embarrassment associated with the degradations of slavery. For whites whose ancestry makes them complicit, there are feelings of guilt about a system that is incongruent with the democratic ideals on which this country was founded. </p>
<p>Cloaked in a veil of silence or portrayed as a benevolent system that was in the best interest of blacks, slavery – much like mental illness – has become shrouded in secrecy and stigma. </p>
<p>Associated emotions are pushed away. </p>
<p>Anger, however, is a healthy emotion, as even the Scriptures acknowledge. </p>
<p>The God of the Old Testament is angry and vengeful. In the New Testament, Jesus vents his anger in driving the money changers from the Temple. </p>
<p>As research (including <a href="http://www.worldcat.org/title/community-mental-health-challenges-for-the-21st-century-second-edition/oclc/845253880">my own</a>) has shown, when anger is internalized and driven deep into the unconscious, contaminated by unresolved pain, it becomes problematic. </p>
<p>So what happens to the anger felt by people discriminated against and, in extreme cases, physically targeted because of their race? </p>
<p>Not enough is known about the relationship between clinical depression and race. But there are extensive findings (including reports by the <a href="http://www.ncbi.nlm.nih.gov/books/NBK44243/">Surgeon General</a>) that attribute racial disparities in mental health outcomes for African Americans and whites to clinician bias, socioeconomic status and environmental stressors (such as high rates of crime and poor housing). And there is <a href="http://www.worldcat.org/title/community-mental-health-challenges-for-the-21st-century-second-edition/oclc/845253880">evidence</a> of a link between perceived racism and adverse psychological outcomes such as increased levels of anxiety, depression and other psychiatric symptoms.</p>
<p>The numbers tell a story. According to the <a href="http://www.mentalhealthamerica.net/african-american-mental-health">Minority Health Office </a>of the Department of Health and Human Services, black adults are 20% more likely to report serious psychological distress than white adults and are more likely to have feelings of sadness, hopelessness and worthlessness than do their white counterparts.</p>
<p>And yet there continues to be reluctance to forthrightly confront the impact of racism on mental health. Some of my colleagues, for example, say that content on race and racism is the most challenging content for them to teach. Authentic dialogue on race is constrained by the fear of being “political incorrect.” It takes less effort to promote the more inclusive liberal view that we live in a “color-blind society.” </p>
<p>It may be easier to allow everyone to remain in their comfort zone. But today as the US faces what would appear to be an epidemic of race-based attacks committed by whites, it is time to examine how our history of racism affects the mental health of African Americans as well as that of whites.</p><img src="https://counter.theconversation.com/content/44642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alma Carten does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Forgiveness, as we have seen in the aftermath of the Charleston killings, is a hallmark of the Black Church. But what psychic toll do these acts of forgiveness exact?Alma Carten, Associate Professor of Social Work; McSilver Faculty Fellow, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/402282015-04-16T04:46:40Z2015-04-16T04:46:40ZMental health services need more money, not a reshuffle<figure><img src="https://images.theconversation.com/files/78143/original/image-20150416-31660-1vxebrf.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">The current level of mental health services funding mean we are already failing people who need help.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/glassified_seconds/8367853144">Davi Ozolin/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>A leaked review of Australia’s mental health services reportedly recommends re-directing a billion dollars of funding from acute hospital mental health services to community services. The proposal risks causing a major destabilisation of the public mental health system.</p>
<p>In 2014, the Commonwealth government asked the National Mental Health Commission to review Australia’s mental health programs and services. Although the review was submitted in November 2014, the government has yet to release it or provide a formal response. </p>
<p>But extracts from the report were <a href="http://www.abc.net.au/7.30/content/2015/s4216497.htm">leaked to the ABC</a> early this week. <a href="http://www.abc.net.au/radionational/programs/breakfast/calls-for-government-to-release/6393584">In a radio interview</a> the chair of the commission, Professor Alan Fels, confirmed the report suggests funding from hospitals be redirected to community services. Fels also pointed out that the terms of reference required the review to work within the existing “funding envelope”. </p>
<h2>False boundaries</h2>
<p>If we are to have an honest discussion about mental health services, we have to move beyond the artificial imposition by the Commonwealth to work within current levels of funding. Few people who are familiar with the sector would argue overall funding for mental health services in Australia is anywhere near adequate. </p>
<p>Indeed, the entire mental health system is under-funded; it’s critical to substantially increase what it gets. The answer is clearly not to re-direct money from one under-funded component of the system (hospitals) to another under-funded component (community services). We shouldn’t have to rob Peter to pay Paul!</p>
<p>Patients prefer to be treated in the community, but hospitals are a critical component of the mental health system for very unwell patients. And right now, it’s actually very difficult to get unwell patients hospital beds.</p>
<p>Of course, community services are very important too and ideally we would be able to effectively prevent mental illness. But while <a href="http://www.ncbi.nlm.nih.gov/pubmed/21854682">there’s some evidence</a> that early intervention may reduce disability for some young people with psychosis, there’s no convincing evidence that such services reduce the prevalence of illness. So while we would like to prevent mental illness in the community, we are not yet in a position to do so.</p>
<h2>A vicious cycle</h2>
<p>As well as being a psychiatry academic, I look after mentally ill patients in a teaching hospital (most with schizophrenia, bipolar disorder or severe depression), so have first-hand experience of the public mental health system, both inpatient and outpatient. There’s no doubt that the whole mental health system is as “tight as a drum”.</p>
<p>Consider this hypothetical and not uncommon scenario based on my clinical experience: John is a 26-year-old man with schizophrenia. Despite active and timely intervention by the local community mental health team, he develops no insight into his condition and continues to refuse medication. </p>
<p>He becomes increasingly agitated and aggressive, threatening his parents. Unable to manage him at home, the community team seek involuntary admission to a bed in the local mental health ward. </p>
<p>If beds are immediately available, he can be admitted urgently. If not (as is sadly very common), the community team need to deal with an increasingly fraught situation in difficult circumstances, particularly if the patient is also voicing suicidal impulses. </p>
<p>Unfortunately, even once admitted, pressure is quickly on the inpatient team not to prolong John’s admission, even if that’s the only way to help him. Hospitals have “bed managers” who are employed to facilitate rapid discharge back into the community. And so continues a cycle that fails everyone in the system.</p>
<p>The answer is clearly not to play off community against hospital services. Both are critical elements of an effective mental health system. </p>
<p>So rather than moving inadequate funds around the system, we need to do what it takes to provide quality modern mental health services. People who suffer from these common and highly disabling illnesses deserve nothing less.</p><img src="https://counter.theconversation.com/content/40228/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Mitchell receives funding from the Australian National Health and Medical Research Council.</span></em></p>A proposal to re-direct a billion dollars of funding from acute hospital mental health services to the community risks causing a major destabilisation of the public mental health system.Philip Mitchell, Scientia Professor & Head of the School of Psychiatry, UNSWLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/381242015-02-26T14:34:52Z2015-02-26T14:34:52ZWhy we never learn: abuse, complaints and inquiries in the NHS<p>In a Commons debate in 1971, Keith Joseph, then the secretary of state for health and social services, said: “There is no doubt that the occasional scandal does an enormous amount for a social service.”</p>
<p>Joseph was speaking about a White Paper released in response to the first major scandal uncovered in a British hospital. In 1967 a nurse at Ely Hospital, a long-stay mental health institution in Cardiff, told the press about the systemic brutality against vulnerable patients.</p>
<p>Joseph was right – scandal can provoke change. But the <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/407187/KL_lessons_learned_report_FINAL.pdf">Lampard report into Jimmy Savile</a>’s activities in NHS hospitals over nearly a 50-year period highlights that yet again, <a href="https://theconversation.com/before-jimmy-savile-there-was-mr-g-the-1920s-philanthropist-who-abused-children-in-hospitals-38061">lessons have not been learned</a>. </p>
<p>Since the Ely scandal (and there was widespread, institutionalised abuse in hospitals well before then that was not properly investigated) there have been more than 100 formal inquiries into NHS failings. These include, to name just some of the most prominent: the abuse of mentally ill patients at <a href="http://hansard.millbanksystems.com/commons/1978/nov/21/normansfield-hospital">Normansfield Hospital in 1978</a>; nurse Beverly Allit’s attacks on children at <a href="http://www.independent.co.uk/news/chances-to-stop-killer-nurse-were-missed-allitt-report-highlights-understaffing-1393483.html">Grantham and Kesteven hospital in 1992</a>, and the <a href="http://www.nursingtimes.net/nursing-practice/francis-report/">Francis report into practices at Stafford hospital</a> in 2013. They include verbal, physical and sexual abuse of children, the elderly, the mentally ill, and sometimes of NHS staff.</p>
<h2>Let’s have an inquiry …</h2>
<p>Inquiries are usually set up by, and report to, the secretary of state for health. Since Ely, they have become routinised – adopting similar objectives: establish the facts, learn from events, provide catharsis through reconciliation, reassure and rebuild public confidence, identify those accountable, and also to meet a political objective of showing the public that “something is being done”. </p>
<p>History show that whether the minister takes action is dependent on wider factors, such as the power of the medical profession, poor industrial relations, economic crises and wider institutional barriers to change.</p>
<p>Serendipity plays a role too in the impact of inquiries. When the minister for health, Keith Robinson, was confronted with allegations of abuse of elderly residents in public institutions in 1965, his initial reaction was a refusal to investigate cases where patients or their relatives wished to remain anonymous, for fear of possible reprisals from NHS staff. </p>
<p>The <a href="http://archiveshub.ac.uk/data/gb97-aegis">pressure group AEGIS</a>, formed by Barbara Robb, collected evidence which was published in 1967 under the title Sans Everything. One of her key allies was <a href="http://www.independent.co.uk/news/obituaries/obituary-professor-brian-abelsmith-1303950.html">Brian Abel-Smith</a>, an academic who was an informal government adviser on health policy, and a hospital governor. Abel-Smith suggested that Robinson appoint Geoffrey Howe QC to chair an inquiry. </p>
<p>When Howe was worried that the report of his 16-month inquiry would be “buried” by senior civil servants, Abel-Smith persuaded the new secretary of state, Richard Crossman, to publish it in full, and to set up a “Post-Ely” working party to consider how to implement the inquiry’s recommendations. Abel-Smith also advised Crossman to set up a Hospital Advisory Service to perform regular inspections of hospitals and to establish a <a href="Health%20Service%20Ombudsman">Health Service Ombudsman</a> to handle patient complaints.</p>
<h2>… and do nothing</h2>
<p>Progress on setting up the Hospital Advisory Service and Health Service Ombudsman was hindered by an obstructive medical profession. They could see no justification for another complaints procedure, as medical negligence cases were handled by the General Medical Council. Although patient complaints were the subject of an inquiry by Sir Michael Davies QC in 1976, there was no further action till a 1981 Health Circular to NHS authorities. </p>
<p>Before the <a href="http://www.legislation.gov.uk/ukpga/1985/42/enacted">1985 Hospital Complaints Procedure Act</a> there was no consistent approach across the NHS. Patients rarely made formal complaints: in 1971 there were 9,614 written complaints about hospitals. By 2011-12 this had increased to 107,259, partly an impact of new initiatives such as the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671516/pdf/bmj00152-0006.pdf">1991 Patient’s Charter</a> which set out explicit rights for patients.</p>
<p>Until the 1980s, hospital patients were much more subservient and unquestioning about their care and medical treatment. Rigid medical and nursing hierarchies also discouraged junior staff from making complaints or raising concerns about the competence of their fellow workers. Patients in mental health institutions were rarely heard from, even at public inquiries. Between 1961 and 1981 there were eight official inquiries into conditions and abuses in special hospitals such as Broadmoor – and no ex-patient was asked to contribute or give evidence.</p>
<p>NHS inquiries now strive for transparency. Increasingly, the public expects openness in the collection of evidence, and rigour in how it is analysed. The Lampard inquiry is unusual for its invitation to a group of historians to provide expertise – but this is absolutely critical to the correct interpretation of events that happened up to 50 years ago. </p>
<p>Historians, especially those working with <a href="http://www.historyandpolicy.org/">History and Policy</a>, are skilled in producing quick, succinct summaries of pertinent context. It is important that the hospitals in which Savile operated are assessed by the management and patient safety standards of that era, not what we would expect in a 2015 NHS hospital.</p>
<h2>Opportunity to learn</h2>
<p>Most of the 100-plus NHS inquiries that have been held since 1967 have highlighted common areas for concern: inadequate leadership, system and process failures, poor communication, disempowerment of staff and patients. To address many of these would require significant cultural changes to attitudes, values, beliefs and behaviours. </p>
<p>There have already been fundamental changes in British society since Savile’s first abuses of patients and staff in Leeds General Infirmary in the early 1960s. We now listen better to children, women are less tolerant of unwanted sexual advances and we are beginning to re-evaluate the cult of celebrity that allowed one man unrestricted access to some of the most vulnerable people in our public institutions. </p>
<p>What we have yet to do is to really learn from history, to put an end to this miserable sequence of systemic errors in the NHS and their subsequent exposure through a public enquiry. Jeremy Hunt commissioned the Lampard report – he is now obliged to ensure that its recommendations, unlike Ely and others, are fully and swiftly implemented.</p><img src="https://counter.theconversation.com/content/38124/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sally Sheard receives funding from the Wellcome Trust.</span></em></p>The health service has a long history both of abuse and the failure to do anything about it.Sally Sheard, Reader in the History of Medicine, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.